314 CASTBLLANI. 



The patient remained in the clinic for several weeks more without having any 

 more thiosinamin injections. The use of a rubber bandage was, however, regularly 

 continued; the size of the leg increased very slightly. In July I advised him that 

 long elliptical strips of the redundant skin should be removed. 



I asked J)r. Paul, surgeon to the General Hospital, to perform the 

 operation and he very kindly consented to do so. The operation took 

 place on the 10th of July. The patient was given chloroform and, 

 after a thorough disinfection, a long elliptical strip of the skin and sub- 

 cutaneous tissue was removed from the anterior part of the leg and 

 dorsum of the foot. The •margins of the wound were brought into 

 contact by means of an interrupted suture. The stitches were removed 

 after eleven days. The wound healed rapidly. Three weeks later another 

 strip of skin was similarly removed from the posterior region of the leg. 

 This wound also healed quickly. The patient left the hospital in the 

 latter part of August, but has been seen by me regularly. So- far, five 

 months after the first operation, the leg is not enlarged; he has been 

 regularly wearing an elastic stocking and at night has used a rubber 

 bandage for an hour after having massage applied. If he does not wear 

 the elastic stocking, and does not employ the bandage, the lower part of 

 the leg becomes somewhat swollen and oedematous, although much less 

 by far than before the operation. 



Case. 2. — The patient, a private case, consulted me in October, 1006. He was 

 suffering from elephantiasis of the right thigh, leg and foot, of twenty years' 

 duration. The skin of the lower part of the leg and foot was extremely hard, 

 inelastic, and covered with numerous small, wart-like protuberances. 



Measurements: Round the ankle, 24A inches; round the calf, 27 inches; round 

 the thigh, 25 inches. 



The patient underwent a treatment of ninety thiosinamin injections, combined 

 with complete rest in bed, the use of the flannel bandages at first, and the India- 

 rubber bandages later. The case improved greatly, the skin becoming softer, 

 more elastic, and much smoother. The circumference round the thigh was reduced 

 to 21 inches, round the calf to 16 inches, and round the ankle to 14J inches. The 

 patient was able to walk with much greater ease and following my instructions, 

 has been wearing puttees and has continued regularly the use of the rubber 

 bandaging twice daily for an hour. He states that if he stops the bandaging 

 and the wearing of puttees, even for two or three days, the leg becomes swollen 

 and oedematous; the swelling disappears, however, after a few hours, rest and 

 bandaging. He refused operation and has not been seen by me lately. 



Case 3. — The patient, a private case from India, had elephantiasis for fifteen 

 years, confined to the lower part of the left leg and foot. He underweirt a course 

 of fifty-six thiosinamin injections, combined with rest, massage, and the use of 

 the rubber bandages. The improvement was very slight; the skin became some- 

 what smoother, but the dimensions of the affected parts remained practically the 

 same. I think that rest, massage, and bandaging alone, without the injections, 

 would have induced the same improvement. 



Case 4. — Singhalese woman, aged 56; admitted to the clinic April 2, 1007. 

 The disease was of fifteen years' standing, and was localized in the lower two thirds 

 of the left leg and in the foot. The skin was thick and inelastic, but not so 

 rouefh as in the other cases. Circumference round the ankle, 10 inches. 



